MedStar Health in the Mid-Atlantic region has taken a novel – and rigorous – approach to the training and supervision of physician assistants. Greg Henry sat down with MedStar EM Director Bill Frohna to find out if theirs was a model worth stealing.
Dr. Greg Henry: When you write a column like mine, you understand what hate mail really is. The piece that I did concerning PAs and NPs – here to be called advanced practice clinicians – caused more ripples than you can imagine. I received multiple letters and phone calls. One particularly thoughtful letter came from a Dr. Bill Frohna, the Emergency Medicine Director of MedStar Health in the Baltimore/Washington area. So compelling was his letter that I’ve invited Dr. Frohna to join me for an intimate conversation in front of our 40,000 readers. Dr. Frohna, please introduce yourself.
Dr. Bill Frohna: My role is that of system leader in emergency medicine working very closely with seven emergency departments that are staffed by employed emergency physicians, as well as two other emergency departments that are serviced by contracted physicians from two other regional groups. MedStar Health is a 30,000 associate, ten hospital healthcare system in the Mid-Atlantic Region. Our departments range from the suburban to the almost rural to high-volume pediatric and adult centers.
Henry: I understand that you came from the military. How did that impact your view of advanced practice providers?
Frohna: I trained at Madigan Army Medical Center from 1988 to 1992; followed by four years of my obligation, also at Madigan. I basically completed a military career from 1988 to 1996 during which we had very experienced PAs working in our fast-track urgent care site of the department, even in a residency training program. And so finishing my obligation and coming east here to the Washington, DC/Baltimore Region, it was interesting to see that in the Washington, DC departments there was not a PA presence. Yet up in Baltimore where I had the opportunity to be a physician leader, chair and chief at a couple of our sites, we had a very PA-friendly environment. And the hospitals there had relationships with training programs, established PA groups, both in the hospital service as well as in the emergency departments. And so coming back to Washington, DC, in my rounds as a leader within our system gave me the opportunity to introduce PAs to the academic site. For example, during 2008-2009, I did this in Washington Hospital Center, where there were no PAs. We introduced the concept of PAs working side-by-side with attending physicians as well as residents. It can be a very good partnership. It must be a very good partnership. And it must be a very good learning opportunity for both sides because that’s the reality of emergency medicine now. And it’s the reality of emergency medicine more into the future.
Henry: I want you take us through how your system hires PAs or NPs. How do you decide what they’re going to do, how they’re going to be graded, how they’re going to be supervised? Explain how you stratify your various levels of providers.
Frohna: This is a work in progress. I would say that we can be considered a better practice and there may be a best practice further down the line. What we’ve done is work with PA leadership. The important point here is the oft-used and probably not well understood words of “alignment” and “engagement.” It starts with recruiting the right PAs. Physician and PA leadership worked together to find the right candidates from the right programs who have the right qualifications and the right interest in emergency medicine as a specialty. After that, it’s about being very clear and transparent with them what that job is and what that entails.
Almost all the PAs coming out of school are inexperienced with emergency medicine. There are rotations and some specializations in training, but not yet in emergency medicine. We recognized the need to provide additional training and education to assure that the new PAs were providing quality, safe emergency care to the patients they were seeing. And it was recognized that that was not going to happen on day one. It more likely may happen on day 180. But there’s got to be a process of figuring out what that training will look like and how you’re going to establish it.
Henry: When hiring a new residency program graduate, we have a general idea of what they’ve been doing the last three or four years. We know what they’ve been exposed to. For PAs, we’re not necessarily sure of their skill sets and if they can see patients in the ED. You have a tiered classification of physician assistants—you call them junior or level one PAs. Tell me about what their educational activities are going to be when you hire them in.
Frohna: From the time of employment to the one year mark, we provide a dedicated and structured educational program. This oversight and education begins with clinical care, in which their care is provided under supervision via shadowed/double-covered shifts. And that’s for the first three to six months. Their progress in this area is assessed through the focused professional practice evaluation, the FPPE, which is completed by the lead PA at our individual emergency departments.
We weave into that time period a structured education program that is basically a rotational topic-by-month series based on common presentations.
Two and a half-years ago we did a needs assessment of our PAs and our physicians and asked: Which are the diagnoses you’re most worried about or that you feel you need additional training on? We developed our own risk reduction core curriculum. From there we came up with the “deadly dozen” from this risk reduction program and we tailored the topic-of-the-month based on that list. We established a didactic session, along with some hands-on – anything from simulation training to electrocardiographic interpretations to image reviews – and this is interspersed over the course of the year, averaging about six hours a month.
Henry: And this continues on, correct?
Frohna: Absolutely. The requirement is that the new junior PA will complete this core content, the rotation of the 12 topics, during the course of a year.
Henry: And then they move on to be what you call in your system a “staff PA,” meaning they have not yet reached what you consider to be an independently functioning PA yet (and I realize there may be nurse practitioners in that group as well). From one to five years the staff PAs are still in some sort of training and supervision mode, is that correct?
Frohna: We allow the staff PAs to provide care to emergency severity index (ESI) triage levels 4 and 5 patients independently. However, there’s always, always a physician available for consultation/review or if one of these ESI 4 or 5 patients hit one of the other red flags that require real-time physician involvement and supervision.
Henry: I want to clarify this: 4s and 5s are what you consider to be lower level patients. Whereas in the billing and coding forms, 4s and 5s are considered the highest acuity patients; correct?
Frohna: Yes. If you have a department that’s kind of cut up a little bit, a fast-track or urgent care side would be where the ESI 4 and 5 patients might go in your system.
Henry: If there was ever a lawsuit about the care provided, the PA would be able to say to the Court: “I have been through a rigorous standardized program, between one year and five years. I still saw certain levels of patients and the most critical or the most confusing still required direct doctor input.” Is that a fair description?
Henry: The key lines of questioning in a lawsuit are often: What did you do? What did you follow? How were you trained? Did you know what to do? A lot of times physicians who are put in the position of having signed those charts don’t know what to say. They don’t even know what training or background a lot of people have. This is the problem I currently have with the system and this is where you guys have set the bar. The model you have is a best practice, and I think it’s terrific. And once the PAs have gone through years one through five with you, then over five years they’re considered a senior provider; is that correct?
Henry: And then they’re able to take on the more advanced cases and they get intervention by the physician selectively in all cases? After five years, how do you decide who can practice more independently, and how do you defend that decision?
Frohna: One other benefit of this type of tiered training for our PAs is this core content that’s a year-long training, and that happens in parallel with their clinical practice over the first two years time, plus an additional number of hours of CME. This allows our PAs to sit for the emergency medicine certification of additional qualification from the PA organization. That certification, which we encourage, provides an additional qualification in emergency medicine, and that becomes an additional marker of quality. Obviously we still need to have reviews from their ongoing professional practice evaluations that occur twice a year and make sure that those two together mean we’ve got a PA who we want to encourage to be with us for the long term. And then once they’re in that five-year mark, we look for ways to engage them further in promotion of their own PA program in being the teacher of PAs and working in more of a higher acuity side of the emergency department and more frequently than the junior PA.
Obviously the rules still apply with regards to real-time supervision. So whether you’re a senior PA or a staff PA – the more junior level – you still can see ESI 4 and 5 patients independently. But the ESI 1 to 3 patients require time of visit supervision by an attending physician. From that perspective, we make sure that all of our PAs understand what’s important to the patients and community we serve, the hospital we serve and our healthcare system in emergency medicine.
And then we engage them by offering them the opportunity to grow and develop as professionals in emergency medicine with this focused training, with a maturation process spelled out for them in regards to their clinical abilities and independence. But they understand and we know that we offer good guidance and ability to monitor that growth and that practice. We have a strong sense of the professional practice of emergency medicine and the model of care of how we deliver it in our emergency departments.
This kind of a system provides clarity. It allows someone to answer to the lawyer if such a situation arises. At a minimum, we have a document that they can refer to, that explains their training.
We’ve established this program throughout seven emergency departments now, with roughly a hundred PAs currently in practice; about a dozen of them just passed the certification exam. So we’ve got a lot of PAs who are engaged in this process and helping grow and develop it and then making sure that it works.
And obviously I have to acknowledge all the physicians in our group because to work effectively with PAs, you have to establish the culture. Everyone has to understand: What’s the value behind it? What are the behaviors we expect? With that culture, we can establish a successful PA and physician collaboration that ultimately provides patients with the safest, highest quality care.
Henry: There are always fine points here which we need to be discussing. When we get into the supervision policy, even on the most complex visits – there are unstable vital signs an admission directly to the operating room or other significant red flags – you still require physician involvement, correct?
Frohna: Yes, a physician needs to be there even with the lower acuity patients who trigger one of those flags: An urgent care side patient who may have a return visit for the same complaint within seven days; a baby or a child less than three or six months, depending on the site; or an elderly patient with a certain age or the abnormal vital sign.
Henry: Let’s talk more generally: Number one, the PA/NP movement is here to stay. Would you agree with that?
Frohna: I would absolutely agree with that.
Henry: Number two, if we don’t have a logical system of dealing with their progression and learning – just like we deal with the physician’s progression and learning – we’re going to eventually run into a situation where we’ve got physicians and advanced practice providers pointing fingers at each other.
Frohna: I would agree with that as well.
Henry: Have you ever had to fire an advanced practice provider?
Henry: And what was it that caused the firing to take place?
Frohna: Most recently a couple of the new-hire PAs who came into our departments really have not understood the basic premise of an emergency provider. This goes back to what I referred to as our guiding principles and mission statement about why we do what we do. And it was clear after their arrival and the way they worked in the department that they just did not get it – they were not a good fit. And this was despite feedback, because we provide feedback in a fairly timely way with this focused professional practice evaluation process in the first three months. But when you’ve got to start meeting with an individual several times within the first month or two, there may just be a disconnect.
Henry: Any other secrets you would like to pass on?
Frohna: Well, one question that readers might have about this whole topic and about the training is the expense associated with it. And it’s an expense associated with the shadow shift: the fact that a senior PA oversees the junior PA for the first three to six months on every case.
So I am very lucky that within our healthcare system, safety is job number one. We have an understanding that there may be an expense associated with it early on, upfront, but it will pay dividends or hopefully will not – fingers crossed – generate additional expense from indemnity payouts later on. Given the focus on safety in the system, our leadership understands what this program is all about and they’re standing by it. When you’ve got discussions about safety and high reliability organizations, all this type of stuff, I can point to this program as being an initiative that fits and meets all the aspects that one would want in such a program: eliminating variability, establishing standardization, clarification of the obligations of the physician and the PA, the supervisory role we discussed, the signatory stuff. All those type of things are established.
And sitting in on the corporate risk management discussions, I’m obviously aware that there are more and more cases involving PAs coming forward for discussion and for trial, etc. And I think that this is a key part of us as emergency physicians, emergency providers being seen as the solution to some problems. And if we can be seen as the solution rather than the cause of a problem, that’s what we’re about as a specialty as emergency medicine. And that’s what our PAs and physicians as a team will be part of: the solution rather than the problem.
And the other thing I would say is that when you establish such a program, you have to circle back and make sure people are doing what they say they’re doing. You should have someone there who confirms, “Yup, we’re staffing 4 and 5 cases for the first three months.” Fine. I really do trust our leaders at each of our sites. But when a case from a couple years ago just came up – from one of the other hospitals in the region – there wasn’t a PA/physician discussion that should have taken place, as was documented in the guidelines policy at the site. Where they said that an ESI Level 3 patient should have real-time supervision by a physician, that didn’t occur.
Henry: Well, there’s nothing worse than having them read your own guidelines to you in Court and then you having to say: “Well, in this case, we made an independent decision.” That never goes well in front of 12 people who are now spending a lot of their cash on healthcare. They don’t like it.
Frohna: That’s true.
Henry: Bill, I want to thank you so much for being a part of “Oh Henry” this month. Your letter was a breath of fresh air. It made no comments as to my parentage. It in no way insinuated I should eat something foul and expire.
And the framework you’ve established is really where we need to be in emergency medicine. This is what the Board of ACEP needs to do. It needs to set up these sort of guidelines and programs and best practices, so that we can assure quality care at the most reasonable cost.